Saturday, May 1, 2010

Do Unto Others...

Recently I was having lunch with my friend and the conversation drifted towards each others’ health and the results of my recent blood work which showed that my hemoglobin is on the lower side of normal. “Dude, I’ve transfused people with hemoglobin that low”, she said when I revealed the number. My doctor was a little worried and suggested a transfusion but I turned her offer down without even thinking about it. I told her that I couldn’t bear the thought of having to wait in an emergency department for hours to get a unit of blood. Besides, I was asymptomatic and somewhat proud of my ghostly pallor. “I promise I’ll take my iron more regularly and eat more spinach” and with that I skipped out of there and headed to my favourite Thai restaurant. Needless to say my doctor was a little pissed. When I told my fellow nurse about the whole ordeal she said that were she in my shoes, she would also have rejected the offer but not for the same reasons. “The thought of some stranger’s blood going in you is just gross – I better be on my death bed to consider that option”. I wholeheartedly agreed with her.

A few days after that, I was in the nursing lounge on my break when the conversation drifted towards life saving medical interventions and how much each one of us would personally tolerate.

We talked about how far each of us would be willing to go if we were competent and had the capacity to consent. Some of us wanted everything and the kitchen sink thrown at us while others (well, just me) settled on being heavily sedated and opting for organ donation in case of life threatening injury with little to no chance of recovery. We also talked about procedures and interventions that were necessary to stop further deterioration in a patient’s condition. Of course my favourite loud mouthed nurse had to bring up my refusal to get a transfusion into the conversation.

“I don’t get it! You have no religious objection to getting a blood transfusion but you’re letting an irrational get in the way of something that will probably make you feel better almost instantly! What’s wrong with you child?” asked one of my favourite doctors.

“It’s gross!” (food coma was setting in and capacity for rational argument was decreasing exponentially).

“So you think all the people who get blood transfusions are also gross?”

“NO! I just find it repulsive if that were to happen to me but I’ll do it if I really REALLY have to!”

“If I were your doctor I wouldn’t let you leave until you consented! I think you’re being very silly and a unit of packed red cells would probably make you feel a lot better very quickly”.

“But I haven’t had any symptoms associated with low hemoglobin and I’m taking my iron pills so I see no need to get a transfusion just to boost up my lab values”.

Inevitably, my break ended but it got me thinking – how often do we push aside patient autonomy for percieved beneficence? How often do we manage to ‘convince’ our patients to do what we think is right for them or their families despite their beliefs? If my brief conversations with my friends and colleagues yielded such varied view points and disagreements, how would someone who has never had any experience with health care know what the right thing to do would be? Would I be upset with a patient who rejects an important procedure due to an ‘irrational’ fear or plain old disgust? I hate to say it, but there have been times I have been a little annoyed. Back in nursing school, I figured “Do unto others as you would have them do unto you” would be a good rule to follow but now that I can’t even decide what I have others do to me, I find it harder and harder to argue with families when they want something that I may not agree with.

19 comments:

I also realized years ago when I was a patient myself that I didn't agree with/care to follow my doctor's orders all the time. This has helped me a lot as a healthcare provider to work with patients to find mutually acceptable treatments and to understand why patients are often "noncompliant."

I also like the philosophy of one of the MD's I used to work with - that as an MD they were an "advisor," there to assess and present options, not necessarily to tell people what to do. This leaves the decision and accountability with the patient, who is ultimately responsible for their own health.

I love it... I grapple with this often. I've recently started working in a harm reduction service, and it has been a huge learning curve, as I support people to harm themselves with drugs and alcohol in a safer way for them and their fellow users... The amazing thing so far is, that as I've let go of my trying to convince, and adopted the "here are your options, and whatever you decide I will support and try to help make work for you". So far this includes helping them find veins that aren't shot, so they can stop or reduce injecting into their groin or jugular. Intense and bizarre, and yet I'm finding it really satisfying, as I see people who have been with the service for years and the level of trust and change that is possible, as they engage with the people I work with when no one else would touch them due to their non-compliance.

But but but.... WHY is your Hgb so low? (You don't need to share, but of COURSE that's what I immediately started thinking.)

I also don't like the idea of transfusion for myself, but that's mostly because I don't like the idea of my health ever not being good, and accepting such an intervention (for me) would be an admission of that -- and that I'm getting "old". I know that thinking is a bit pathological, but there it is. And yes, I know that I will one day have to accept that my health is no longer perfect, but I'd like to put that off for as long as possible!

I wish the whole system didn't get so bent out of shape and come to a crashing halt when someone refuses a particular treatment.

My wife and I had this issue with our latest child. My wife had a placenta previa. She had one with the baby before also--completely asymptomatic, and resolved on its own. So we refused the weekly sonograms to monitor it this time. Just not necessary as long as she remained asymptomatic. We almost got fired by our midwife over that.

If someone who is competent doesn't want something and they understand the consequences, so be it...I'm their nurse not their mother. What bothers me is when the folks deciding for somebody else don't take into account the impact on the person who is the benefucuary of their decsions. That is the much stickier wicket.

After the birth of my 1st baby, I had a PPH, and my Hgb went from 135 antepartum to 88 post-partum. I was offered a transfusion, but decided against it, not for any real religious or philosophical reasons, nor because it's "gross." My feeling was that it wasn't necessary. I'm young, healthy, and asymptomatic (other than feeling tired, which comes with having baby, doesn't it?), and felt I'd bounce back pretty fast. Save the blood for someone who really needs it, like that cancer patient, you know? And I was right. I took my iron, took advantage of the ton of family support that was offered me, and by 4 wks post partum, my Hgb was 125.

As a long time blood donor, I don't see transfusions as being gross. But I'm well aware of what a precious resource it is, relying solely on the generosity of strangers for the supply. So my belief is that only those who truly need it should get it. Had I been symptomatic following my PPH, I might have accepted the blood.

But for crying out loud, take your iron! (and your folic acid and B12, for that matter!)

You're probably more than aware, but per chance not, cream of wheat is a great source of iron, and in a form that's readily taken up by the body (better than green leafy vegetables or liver, even). Total cereal, also contains lots. Both fairly yummy comfort foods in my opinion.

I'm with you there. I would refuse a transfusion if it was anything above 80 (and even into the 70's). especially if you're Asymptomatic. As healthy adults we have the ablitly to recover with levels that "low".

I totally support your decision and I know alot of nurses would.

I think it's become a soceity of "But we can do it." and somewhere along the line we stopped asking "Should we do it."

Just because we CAN transfuse... WHY? should we. Like you said if it's just going to boost your lab values.. eh it's not worth it. (Different case if you were symptomatic of course).

Anyway like you said take your iron pills, each spinich and iron rich cereal and i'm sure you'll be fine.

Remember - severe anemia is also not without risk. I would think you would be more at risk for ischemic events etc. You didn't give us a number but I'm really hoping it's greater than 7. I totally support your right to make your own decisions but I second those above who want you to pursue finding out the original cause. Meanwhile - Chinese broccoli beef for you!

Just keep an eye on it. I was never low, low, but I've always been "anemic". So when I get the, "you're anemic" rant, I pull out the hematology report, let 'em read it, and they leave me alone. Certain blood disorders are hereditary.

And no, if you're not sure about what's causing your anemia, go visit the hematologist. It sure beats guessing!

I was walking around with a hemoglobin of 7. At the time, I had just started nursing school and was working full time NIGHT SHIFT as a PCT, constantly rotating from a normal person's schedule to a night shifter's schedule.

I ended up being referred to a specialist and ended up being diagnosed with a condition that I'm on medication for. My hemoglobin is now normal and I feel fine.

But for several weeks before I ended up going to the doctor everyone would always ask me, "you're so pale, are you feeling alright?"

And when they got my lab work they asked me, "haven't you been tired?"

My response? "Well yeah I've been tired, I work full time and I'm in nursing school; wouldn't YOU be tired?!".

Anyways, I know that wasn't the point of this post, it just makes me feel like superwoman that I could do all that with a hgb of 7.

I resisted until I ended up with a hg of 6.My sister had just given blood a few weeks earlier (and 300 miles away), but I kept telling myself it was her blood as they hung those units. That got me beyond the "ick" factor and I took three units.A little denial at the right time can get you through it.And I am kinder to my patients now when I hang blood.

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Refusing a hep vaccination for my newborn and the nurse wen balistic because how could i be sure to not have hep and transfering it to my baby?

Well lets see,,my first test at three months preggers was negative, i do not work with sick persons, do not have tattoos, had no operations, no blood transfusions, no changing sexual partners, and no drug use.

She was ranting pretty badly how i was risking my babys health...she looked as if she wanted to whack my head.

I still refused and went home with my baby. My second blood test after birth which was not done when the nurse attacked me, was also negative...haha

I also refused a blood transfusion after birth..someone would need it more than me, i was a little pale but I live....still

I also did not want to go to thehospital which my doc encouraged when i had a bad, bad time with my Crohn where i shat water...I drank water and then it came out nearly clearn at the other end...but i got my medication and some minerals, lots of water and 3 days later I was as good as new. Oh and after the visit to my doc and the recommended transfer to the hospital I went grocery shopping.

This was a very interesting post to read! I wind up having to fight with medical staff all the time because I'm 29 and have a DNR. It doesn't matter to them that I'm terminal. All they can see is that a 29 year old is refusing care that could prolong her life. Your post today has made me think about how it must be a tricky line to walk for the medical staff. This post has made me realize that I need to be more patient with the medical staff. Thank you for helping me realize that I need to see it from their point of view!

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